Tonight, I’m going to forego the normal format for The Drift and I want to talk about the accident on the Fitzgerald that claimed the lives of seven sailors.
Most of you know I am a former sailor, but you may not know that I was an Operations Specialist 2nd Class, a surface watch supervisor and performed the job where some of the most crucial breakdowns on Fitzgerald occurred. I sat on the headset with the bridge, trading contact information, making contact reports and course and speed recommendations, and generally tried to keep surface trackers on task with mixed results
I wasn’t perfect – if you can dig up Operations Specialist Senior Chief (Ret.) Glenroy Walkes he will certainly attest to the fact that I had my shortcomings – but having this in my background gives me some insight into the events on Fitzgerald that evening.
This week, ProPublica released two stories on the Fitzgerald: one about the accident, and one about the aftermath and the years of warnings about the condition of the surface fleet that preceded them. The reports are worth reading and, particularly the second article, has some very intriguing insights from key players from the past decade.
There is a danger, however, of coming away from the reports with a narrative that the material condition of the ship and its radar systems caused the accident, and the material degradation was the fault of a higher command that made readiness secondary to other priorities. It is my belief that the Admirals and civilian leadership failed the Fitzgerald and her sister ship McCain, but tonight I want to focus on something much less comfortable than blaming bungling flags: I want to talk about how the Fitz watchstanders failed their shipmates.
I hope you will bear with me, I think this is important.
The Fort Report
About two months ago I got an email from my friend and colleague Geoff Ziezulewicz that caused my heart to sink: he had the Fort Report, the investigation into the Fitzgerald collision conducted by Rear Adm. Brian Fort. I didn’t really want to read it, I hated the idea of stirring up the anger and sorrow this accident causes me every time I think about it, but I read it. Front to back.
It’s the same report ProPublica used for much of the narrative in its story, but I think there is some value in me going through it to single out the things that jumped out to me about why this accident happened based on my professional training as an OS and as a journalist.
According to the Fort Report, the 2200-0200 on the bridge of the Fitzgerald was close to coming to an end when the Fitzgerald got into a crossing situation with the ACX Crystal. Fitz was the give-way vessel, which means that Fitz was crossing the Crystal’s bow and, under the international rules of the road, Fitz was required to maneuver to avoid a collision. By the time the officer of the deck on Fitzgerald, Lt. JG Sarah Coppock, was fully aware of the danger she was in, it was too late to save the ship.
Two minutes before the collision, Coppock began swearing that she was “going to get fucked for this.” Still, despite knowing the danger, she neglected to sound the collision alarm, a crucial warning that the sailors sleeping below deck were denied. The first warning sailors below deck received that they were in mortal danger was the collision. Some not wakened by the crash were roused out of bed by water coming into their racks.
The actions leading up to that tragic moment are inexcusable.
The combat information center (CIC) is tasked with monitoring all sensor inputs to create a cohesive surface picture of all the ships detected in the area. Sensors and systems include surface search radar, Automatic Identification System and a tool called the Digital Dead Reckoning Trace that allows a watch stander to trace the ship’s movement through the water and plot with a ruler the bearing and range of any surface ships in the area. The final result on the DDRT ends up being a bunch of lines and connected dots on a large white sheet of rolled paper that gives you a fairly accurate idea of the course, speed, bearing and range of any ships in the area.
Both the CIC and bridge are required to plot any surface contacts with a closest point of approach within some number of miles of the ship on what is known as a maneuvering board, or “moboard.” On the moboard, you take three or more fixes of bearing and range to a contact from your own ship, thereby establishing a track, a course, speed and closest point of approach (CPA), as well as time to CPA.
Any ships that could pose a danger, CIC is supposed report to bridge, along with a course and speed recommendation to avoid the oncoming ship. The bridge is also required to track all surface contacts and work their own solutions, using CIC to compare notes. Redundancy is the Navy way.
On watch in CIC, there would have been: a very junior OS in charge of tracking surface contacts, making sure that everything around the ship has a good track in the combat system; a slightly less junior Surface Watch Supervisor (SWS) in charge of the junior OS watchstanders on the surface side; a Surface Warfare Commander (SUWC) who is the senior-most watchstander on the surface side of CIC, as well as a CIC watch supervisor (typically an First Class OS).
And, over all, the tactical action officer (TAO). The TAO is the Captain’s representative in combat: the only person who has authorization to fire weapons in defense of the ship without the captain’s permission and the ultimate authority in CIC on any given watch.
Before Cmdr. Bryce Benson, Fitz’s commanding officer, hit the rack for a few hours of sleep, he left what’s known as “night orders.” Night orders are contained in a binder to be reviewed and obeyed by watchstanders while he was getting some rest. On the night in questions, the orders included:
- The CO shall be notified of any contact with a CPA of 6000 yards
or less. This report should be made at 10000 yards (5nm) or 20
minutes prior to a calculated CPA (whichever occurs earliest).
- The Officer of the Deck shall maintain a maneuvering board plot
on all contacts with a CPA of 10000 yards (5nm) or less.
- Maneuvering boards shall be used on the Bridge and CIC for surface
tracks with a CPA of 10000 yards or less. The DDRT shall also
be used for such contacts.
- The OOD is required to call the Commanding Officer when in doubt.
Between 2200 and the collision at 1:30, the bridge and the combat information center shared no surface contact information with each other.
The radar operators reported getting lots of junk returns around their own ship, known as “sea clutter,” which was the result of the radar being in a configuration that is normally reserved for steaming in the open ocean. In those conditions you want to focus on contacts that are far away from the ship to plot ways to avoid them well in advance. When you are close to land with lots of traffic around the surface radar should be in short pulse, which gives watchstanders a higher-fidelity view of what’s closer to the ship.
When investigators examined the equipment, they found that the switch that toggle that changed the radar from short to long pulse on was inoperable on the console in CIC, and was in long pulse because it had been set that way in the local control radar room outside of CIC. It’s likely it had not been in short pulse all year, the investigation found. This is a shortfall in understanding radar fundamentals, which is standard in-rate knowledge for operations specialists.
The surface watch team also didn’t use the DDRT as per the CO’s night orders.
An hour before the accident, the OOD made a contact report to the CO about four vessels on their port side, but at no point did the bridge contact CIC, nor did CIC contact the bridge, concerning the contacts.
The OOD made no other calls during her watch, although over the next hour, FTZ would pass at least five other contacts with CPAs meeting the CO's Standing Orders criteria for a contact report to him. One of these unreported contacts passed down FTZ's starboard side at approximately 650 yards at just 22 minutes before the fatal accident.
Neither CIC nor the bridge made contact reports or made moboard solutions for any of the contacts. It’s worth noting that CIC did not have a track on any of those contacts, likely due to the radar being in the wrong configuration, something the OOD might have discerned if she had asked the SUWC or the SWS what they had on them. She did not.
The SUWC had an Automatic Identification Systems (AIS) display next to his console, but at no point did he seem to match the AIS picture with the picture on his screen. At no point did he seem to wonder why things that were appearing on AIS were not on his radar scope or input into the combat system.
In fact, during the entirety of the SUWC’s watch, he doesn’t seem to have done much of anything because he made precisely zero contact reports or recommendations.
The TAO sits in front of large displays that synthesize all the sensor data in such a way so the watchstander can simply click on an individual contact to get the history, identification (if any), course, speed and CPA. But at no point in the watch did the TAO click on a single track, according to the investigation, and investigators found it was likely that she was doing paperwork instead.
Both the CIC Watch Supervisor and the SUWC left for 10-minute bathroom breaks during the crucial half hour before the collision.
Ten minutes prior to the collision, the junior officer of the deck looked out of the starboard bridge wing and recommended to the officer of the deck that she slow the Fitz to address an increasingly tenuous situation developing with a group of contacts, including the ACX Crystal. The OOD disagreed, saying that slowing would complicate the picture, but its unclear how she would know that because it does not appear the watchstanders had done any of the work to figure out what course and speed would best avoid the close CPAs.
Despite the apparent doubt and the order from the CO to call in cases where they had questions, they did not alert the captain.
At no point prior to the collision did Benson, the commanding officer, have a chance to effect the outcome of the disaster in the works that evening because neither the OOD nor the TAO called him to alert him to the danger.
At 1:30:34, the disaster struck.
Rear Adm. Fort found four main causes of the collision.
- The Fitz OOD demonstrated poor seamanship contrary to the International
Rules of the Road.
- The Fitz Bridge and CIC Watchteams, jointly and individually,
failed at the basic principles of Bridge Resource Management
– a term that means using all resources available to CIC
and the bridge to safely navigate the ship.
- The Fitz commanding officer abdicated his responsibility for
safe navigation during the outbound transit from Sagami Wan to
- CRYSTAL's Second Officer demonstrated poor seamanship contrary
to the International Rules of the Road.
The failings of the OOD, the watchstander most responsible for the safe navigation of the ship, are apparent on their face. But the less remarked upon failings of CIC are worth quoting in detail:
Excerpt: The Tactical Action Officer (TAO), LT Combs, and her watchteam failed as completely as the OOD and her watchteam. As a TAO, the FTZ Operations Officer, and the most senior person on watch during the collision, her performance was significantly below standards. She was derelict in the performance of her duties by failing in her duty as a primary advisor, supervisor, and mentor to the OOD.
Given that FTZ was too close to land to radiate the SPY-lD radar, the TAO was free to dedicate her complete focus and attention on supporting the Bridge watchteam as it negotiated a night time transit out of Sagami Wan in moderately dense traffic. Based on her complete Jack of situational awareness, her complete lack of interaction with the OOD and her watchteam, and the volume of paperwork discovered in the vicinity of the TAO seat following the collision, she was most likely consumed and distracted by a review of Operations Department paperwork for the three and a half hours of her watch prior to collision vice standing a professional, vigilant watch.
The Surface Warfare Coordinator LT Woodley, and Surface Watch Supervisor, OS2 Stawecki, were derelict in the performance of their duties in leading the Surface Watch Team in that they failed to maintain an accurate surface contact picture.
The SUWC demonstrated no situational awareness for the expected navigation track …, had no navigational understanding of the expected flow of traffic, and made no effective use of AIS to support his situational awareness. Both the SUWC and SWS simply accepted the challenges that the clutter on the SPS-67 radar return presented them and accepted that manual tracking was the norm because of a concern that using the auto-tracking feature would crash the system. Fundamentally, the Surface Watch Team allowed FTZ to effectively navigate in the blind from CIC, and CIC leadership passively accepted that "it was a quiet night."
The Combat Information Center Watch Officer (CICWO), LTJG Moncravie, and the Combat Information Center Watch Supervisor (CICWS), OSl Graham, were derelict in the performance of their duties to properly supervise subordinate watchstations in CIC, specifically the Surface Watch Team. The CICWO and CICWS contributed nothing to the safe navigation of FTZ other than recording the ship's position every 15 minutes. Further, the CICWO and CICWS failed to forcefully back up the TAO or Surface Watch Team or demonstrate a questioning attitude with respect to the number and close range of SPS-73 contacts being tracked by the OOD on the Bridge (and being displayed on VMS in CIC) compared to contacts being tracked by the CIC Surface Watch Team.
The Comprehensive Review triggered by the accident first on Fitzgerald then on McCain, led by a command that escaped major scrutiny around its potential role in some of the underlying readiness issues in the Japan-based U.S. 7th Fleet, uncovered a culture of systemic corner-cutting and relaxed standards in service of meeting operational tasking.
Ships were routinely being given waivers for major certifications and ships, such as the Fitzgerald, that were in serious need of corrective maintenance for a whole host of issues were being pushed beyond what was safe. And in that climate, its small wonder that laxity and declining standards began showing up on the deckplates of ships in 7th Fleet.
Many officers paid for these accidents with their careers. Others escaped scrutiny but will have to deal with their role on their own terms.
But tonight, that’s not what we’re talking about. We’ve been talking about watchstanders and their responsibility.
When you assume a watch, in the words of the general orders of a sentry, you take charge of your post and quit only when you are properly relieved. There will always be headwinds to doing your job in the Navy or in any organization, but it’s just not an option to use those headwinds as an excuse to not do your job.
When investigators assign blame for an accident, they look first for the main factors then list the factors that may have also contributed. And in this case, it is difficult to say the main factors that caused the collision between Fitzgerald and the ACX Crystal are anything but clear: Watchstanders on the bridge and in CIC did not stand a proper watch.
According to the investigation, the TAO was likely doing paperwork on watch. The SUWC was profoundly disengaged, not making a single contact report to the bridge for the duration of the watch. The SWS was working hard but failed to ask why he might not be getting the best radar returns on his scope. The CIC Watch Sup, an experienced First Class OS, didn’t ask those questions either.
It is difficult to believe that the 7th Fleet Commander or some Four-Star back in Norfolk made them fall short of their duty. I also strikes me as possible to acknowledge the failings of the higher command and also acknowledge that sailors, on a lower level, also failed to live up to their responsibilities.